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Program to Prevent Perinatal Hepatitis B Virus Transmission in a Health-Maintenance Organization -- Northern California, 1990-1995

Each year, an estimated 20,000 infants are born to hepatitis B surface antigen (HBsAg)-positive women in the United States. These infants are at high risk for perinatal hepatitis B virus (HBV) infection, chronic HBV infection, and associated complications of chronic liver disease, including cirrhosis and hepatocellular carcinoma. All vaccine advisory groups recommend that all pregnant women be routinely tested for HBsAg during an early prenatal visit during each pregnancy to determine whether their newborns will require immunoprophylaxis for the prevention of perinatal HBV infection (1-4). Administration of appropriate immunoprophylaxis is approximately 90% effective in preventing HBV infection among children born to HBsAg-positive mothers (5). In 1985, the Kaiser Permanente Medical Care Program of Northern California (KP) -- a health-maintenance organization (HMO) providing care to 2.5 million members and delivering 30,000 infants annually -- implemented HBsAg screening of all pregnant women. After initiating the program, KP estimated that at least 25% of the infants born to HBsAg-positive women were not receiving appropriate post-exposure prophylaxis. In response, KP implemented a tracking and follow-up program in 1988. This report describes an assessment of the impact of this program, which indicates that a centralized case-management and tracking system can substantially improve levels of post-exposure prophylaxis.

The perinatal hepatitis B program is a component of the KP perinatal section that screens, tracks, and manages test results for HBsAg, syphilis, human immunodeficiency virus (HIV), and alphafetoprotein in pregnant women, as well as the state-mandated screening tests for their newborns. A central database is linked to 32 prenatal clinics, 11 obstetric hospitals, 30 local laboratories, a central laboratory, and 32 pediatric clinics.

The perinatal hepatitis B program maintains a database of all HBsAg-positive pregnant women, including their estimated dates of confinement and designated prenatal clinic health-care providers. A list of the HBsAg-positive pregnant women expected to deliver during the next 3 months is produced weekly and reviewed daily at the central office for patient admission to obstetric hospitals. Staff from the perinatal hepatitis B program verify that appropriate prophylaxis is provided to at-risk infants at birth (hepatitis B immune globulin {HBIG} and first dose of hepatitis B vaccine) by direct communication with the medical staff at the obstetrics hospitals or by review of a faxed copy of the infant's medical record. They continue to track infants using an online vaccination tracking system to verify that follow-up doses of hepatitis B vaccine are administered at ages 1 and 6 months. Reminder letters are sent to pediatric providers before an infant's vaccination visit to ensure administration of the second and third doses of hepatitis B vaccine. The hepatitis B nurse coordinator consults with pediatric providers or designated staff members to schedule follow-up with patients who do not receive vaccines according to the recommended schedule.

Of the 188,498 infants delivered through the KP health-care system from 1990 through 1995, a total of 1712 (0.9%) were born to HBsAg-positive women. Almost all of these infants (1708 {99.8%}) received HBIG and hepatitis B vaccine before hospital discharge. Of the 1511 infants who remained in the KP health plan, 94% completed the three-dose hepatitis B vaccine series by age 6-8 months, and all infants except one were completely vaccinated by age 24 months. KP conducts postvaccination serologic testing to determine whether infants responded to the vaccine or became infected with HBV; however, these results are not tracked through the perinatal program.

Reported by: E Schoen, MD, D Cohen, MPH, S Black, MD, C Limata, MSN, Kaiser Permanente Medical Care Program of Northern California, Oakland. Hepatitis Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Prevention of perinatal HBV infection requires the coordinated transfer of information between outpatient and hospital-based providers to ensure that 1) pregnant women are screened for HBsAg and the results are transmitted to the delivery hospital, 2) infants of HBsAg-positive women receive HBIG and the appropriate dose of vaccine at birth, 3) infant vaccination is completed by age 6-8 months, and 4) the infant is tested after vaccination at age 9-15 months. Prevention programs without intensive case management and tracking have been only moderately successful in ensuring that children of HBsAg-positive mothers are identified and complete the vaccine series by age 6-8 months.

Before the initiation of federal funding of perinatal hepatitis B prevention programs in 1990, only 45% of infants born to HBsAg-positive mothers received appropriate prophylaxis at birth, and few (35%) had completed the vaccine series by age 6-8 months (6,7). In 1990, perinatal hepatitis B prevention programs were implemented nationwide. Despite these programs, only an estimated 40% of the approximately 20,000 births to HBsAg-positive women are identified each year and entered into tracking systems. Of the infants who are tracked, approximately 90% receive appropriate prophylaxis at birth, and 60%-70% complete the vaccine series by age 6-8 months (8). Thus, only 5000-6000 of the 8000 infants who are tracked receive appropriate and timely follow-up; the number of infants who are not tracked and who receive appropriate and timely follow-up is probably even lower.

Because the risk for perinatal HBV infection is increased for infants born to HBsAg-positive women and who have not started the series at birth or who have not completed the vaccine series by age 6-8 months, the appropriate doses of HBIG and vaccine should be provided in a timely manner (9,10). In addition, because of the continuing risk for exposure among infants of HBsAg-positive mothers, postvaccination testing should be used to identify those infants who may not have responded to the initial three-dose series and who may require additional doses of vaccine.

The experience at KP emphasizes the importance of a centralized management and tracking system for perinatal hepatitis B programs; this approach can improve identification, follow-up, and vaccination completion rates of infants born to HBsAg-positive mothers. Centralization ensures that all health-care providers and institutions have access to screening and tracking information -- a need especially important when different health-care providers and institutions provide the prenatal and perinatal care for the pregnant woman, delivery of the newborn, and follow-up care for the infant. In addition to this centralized approach, other important components include dedicated staff, computerized tracking systems, and provider-reminder and/or patient-recall systems (8). As with the prevention of perinatal HBV infection, intensive case management of mothers and their newborns, including centralized case management and tracking, may be useful in preventing other perinatal infectious diseases, including HIV infection, group B streptococcal disease, and congenital syphilis.

References

  1. Committee on Obstetrics, Maternal and Fetal Medicine. Guidelines for hepatitis B virus screening and vaccination during pregnancy. Washington, DC: American College of Obstetrics and Gynecology, 1990.

  2. CDC. Protection against viral hepatitis: recommendations of the Immunization Practices Advisory Committee. MMWR 1990;39(no. RR-2).

  3. Committee on Infectious Diseases. Report of the Committee on Infectious Diseases. 22nd ed. Elk Grove Village, Illinois: American Academy of Pediatrics, 1991:238-55.

  4. American Academy of Family Physicians. Recommendations for hepatitis B preexposure vaccination and postexposure prophylaxis. Kansas City, Missouri: American Academy of Family Physicians, August 1992; order no. 966.

  5. Stevens CE, Taylor PE, Tong MJ, et al. Yeast-recombinant hepatitis B vaccine: efficacy with hepatitis B immune globulin in prevention of perinatal hepatitis B virus transmission. JAMA 1987;257:2612-6.

  6. Birnbaum JM, Bromberg K. Evaluation of prophylaxis against hepatitis B in a large municipal hospital. Am J Infect Control 1992;20:172-6.

  7. Klontz K. A program to provide hepatitis B immunoprophylaxis to infants born to HBsAg-positive Asian and Pacific Island women. West J Med 1987;146:195-9.

  8. CDC. Prevention of perinatal hepatitis B through enhanced case-management -- Connecticut, 1994-95, and United States, 1994. MMWR 1996;45:584-7.

  9. Kohn MA, Farley TA, Scott C. The need for more aggressive follow-up of children born to hepatitis B surface antigen positive mothers: lessons learned from the Louisiana Perinatal Hepatitis B Immunization Program. Pediatr Infect Dis J 1996;15:535-40.

  10. Marion SA, Pastore MT, Pi DW, Mathias RG. Long term follow-up of hepatitis B vaccine in infants of carrier mothers. Am J Epidemiol 1994;140:734-46.




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